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Palliative Care in Oklahoma: Looking Back,






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Palliative Care in Oklahoma: Looking Back, Palliative Care in Oklahoma: Looking Back, Presentation Transcript

  • Palliative Care in Oklahoma: Looking Back, Looking Forward Jeffrey Alderman, M.D. Associate Professor Director, Palliative Medicine OU College of Medicine – Tulsa
  • Objectives
    • Learn about the current state of Palliative Care in Oklahoma
    • Understand the benefits/pitfalls of Inpatient Palliative Care Consultation
    • Explore reasons why physicians have difficulty with Advance Directives
    • Learn what you can do to help patients receive appropriate Palliative Care
  • Case Study: Zelda S.
    • Zelda is 73 years old.
    • She has DM-2, Stage III CKD, and worsening PVD
    • She has been admitted to St. John 4 times in the last 6 months with symptoms from her ischemic leg.
  • Case Study: Zelda S.
    • Zelda is widowed, but has 3 children and 5 grandchildren.
    • Her true love is golf.
    • Her goal of care is to continue playing golf for as long as possible.
  • Case Study: Zelda S.
    • Zelda’s golf playing is limited by pain.
    • Social Isolation.
    • Unclear if Zelda can continue to live alone.
    • Unclear if Zelda ever executed an Advance Directive
    • How can we help Zelda?
    • What if Zelda lives in Oklahoma?
  • How Does Your State Rate? Oklahoma F Hospitals with a Program Oklahoma South Region United States 8/43 401/983 1294/2452 www.capc.org State by State Report Card
  • T ULSA W ORLD Saturday October 4, 2008 State gets failing health-care grade BY KIM ARCHER (World Staff) Writer Oklahoma is failing to care adequately for the sickest of its residents and is one of only three states in the country to receive an “F” for access to palliative care, according to a report released Thursday Alabama and Mississippi also received failing grades, according to the study by the Center to Advance Palliative Care and the National Palliative Care Research Center. The study appears in the October issue of the Journal of Palliative Medicine. Palliative care refers to treatment that concentrates on reducing the severity of symptoms rather than striving to halt, delay or cure the disease itself. The goal is to prevent and relieve suffering and improve a patient’s quality of life. Nineteen percent of Oklahoma’s hospitals with 50 beds or more have a palliative care program, the report said. Most are in larger hospitals in Tulsa and Oklahoma counties.
  • What was measured?
    • Patient access to palliative care services in hospitals
    • Patient access to board-certified palliative medicine physicians
    • Medical student access to clinical training in palliative medicine
    • Physician access to specialty-level training in palliative medicine
    Morrison, RS. et al. AMERICA’S CARE OF SERIOUS ILLNESS: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. Center to Advance Palliative Care/National Palliative Care Research Center , 2008, p.14
  • Why did we fail?
    • Clearly too few Oklahoma hospitals have Palliative Care Programs
    • Too few Board-Certified Palliative Care Physicians
    • Not enough Palliative Care Education for Medical Students
    • No Fellowship Training Programs
  • Conclusions
    • More Oklahoma Hospitals need to develop Palliative Care Programs
    • More Oklahoma clinicians need training in Palliative Medicine
    • We must educate the next generation of providers in Palliative Care
  • University of Oklahoma - St. John Medical Center Palliative Care Service
  • University of Oklahoma St. John Palliative Care Service
    • Started in October 2004 - CAPC
    • Interdisciplinary Team
    • Inpatient Consults
    • Close relationship with Hospice
  • St. John Palliative Care IDT
  • University of Oklahoma St. John Palliative Care Service
    • The Clinical Imperative
    • The Financial Imperative
    • Patient/Family Satisfaction
    • Coordination of Care across Venues of Care
    • The Educational Imperative
    • The Quality Imperative
      • Effective, Patient-centered, Timely, Efficient and Equitable
  • Education
  • OU School of Community Medicine in Tulsa
    • 130 Faculty
    • 70 – 80 MSIII and MSIV Students
    • 54 Internal Medicine Residents
  • Curriculum in Palliative Care
    • All Senior Internal Medicine Residents spend 60 clinical hours rotating on the Palliative Care Service
    • All Residents attend 7 didactic lectures
    • All complete online training in pain and non-pain symptom management
  • Stanford Curriculum
    • Introduction to Palliative Medicine
    • Pain Management
    • Non-Pain Symptom Management
    • Communication in Palliative Care
    • Legal Issues
    • Terminal Care
    • Palliative Care Health Care Policy
  • Clarehouse
  • Curriculum in Palliative Care
    • All Medical Students spend ~9 clinical hours rotating on the Palliative Care Service
    • All Medical Students attend 3 didactic lectures
  • Future Directions
    • No formal measurement of Palliative Care Training
    • Exploring pre/post rotation testing tools
    • Expand training to the College of Nursing
  • CONSULT SERVICE Demographic Data
  • Consult Numbers 119 2005 Consults Requested 250 286 354 Cases 2006 Consults Requested 2007 Consults Requested 2008 Consults Requested Service
  • Patient Volume
  • Patient Volume
  • Patient Demographics 33.3% % Entering Hospice After Discharge 31.1% % Expiring at St. John 10.2% ICU Referrals 118 Admission DRG’s 100 Referring Physicians 53% % Female 20 - 98 67.9 354 Cases Age Range Average Age Patients Seen Disease
  • Patient Payor Source 15.5% % Medicaid 72.0% % Medicare 6.5% No Payor Source 6.0% Cases % Commercial Insurance Disease
  • Background Illness 2.8 2.8 5.1 5.9 7.3 7.9 10.5 18.1 39.5 % 10 Other Diseases 10 Renal Diseases 18 Gastrointestinal Diseases 21 Infectious Diseases 26 Bone Disease/Fractures 28 Neurodegenerative Diseases 37 64 140 Cases Pulmonary Diseases Cardiovascular Diseases Cancers Disease
  • Reason for Consult % Number 0.6 2 Other 11.3 40 Non-Pain Symptom Management 18.1 64 Terminal Care 30.8 109 Direction of Care 39.3 139 Pain Management
  • Nephrology 1% OB/GYN <1% Emergency Med 1% Neurosurgery 1% Cardiology 2% Non-OU Internal Med 27% Family Medicine 5% Cardiovasc. Surgery 1% Hospitalists 20% General Surgery 1% Oncology 5% OU Internal Med 35% Referring Physicians
  • LTAC/SNF – 9.9% Other – 2.7% Expired – 31.1% Clarehouse* – 2.3% Nursing Home – 14.7% Home – 39.3% *’Clarehouse’ is a hospice home in Tulsa, providing care to patients in the last month of life Discharges
  • Clinical Outcomes
  • Initial Evaluation Final Evaluation Severe Mod. Mild None Reported Pain Scores 130 Patients seen on the SJMC Palliative Care Consult Service: Oct 2005 – Oct 2006 212 Patients 212 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007
  • Initial Evaluation Final Evaluation Severe Mod. Mild None OU/St. John Mt. Sinai Hospital, NYC* Comparison of Pain Scores 212 Patients 3707 Patients * Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.
  • Initial Evaluation Final Evaluation Severe Mod. Mild None Reported Dyspnea Scores 112 Patients 112 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007
  • Initial Evaluation Final Evaluation Severe Mod. Mild None OU/St.John Mt. Sinai Hospital, NYC* 112 Patients 2219 Patients Comparison of Dyspnea Scores *Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.
    • Agitation 61.1% Reduction
    • Nausea 82.1% Reduction
    • Constipation 67.3% Reduction
    • Dry Mouth 62.9% Reduction
    • Insomnia 75.9% Reduction
    Other Clinical Outcomes
  • Satisfaction Outcomes
  • Telephone Survey of 67 patients/families following discharge date of at least 30 days. Patients were picked at random. Responses from 43 completed surveys are recorded above. 2.9% 0.0% 14.3% 14.3% 68.6% Overall assessment of Palliative Care team 3.4% 10.3% 0.0% 24.1% 62.1% Degree to which discharge process was smooth/hassle free 8.3% 5.6% 2.8% 19.4% 63.9% Degree to which team addressed your overall well-being & comfort 0.0% 0.0% 5.9% 20.6% 73.5% Degree to which team treated you with respect and dignity 0.0% 0.0% 6.5% 22.6% 71.0% Degree to which team included you in decisions about care 3.8% 3.8% 0.0% 15.4% 76.9% Degree to which team addressed Spiritual needs 3.6% 3.6% 7.1% 14.3% 71.4% Degree to which team addressed Emotional needs 2.9% 2.9% 5.7% 11.4% 77.1% Degree to which symptoms (other than pain) were controlled 2.6% 5.3% 7.9% 15.8% 68.4% Degree to which pain was controlled Poor Fair Good Very Good Excellent Question:
    • 83 – 94% responded very favorably, reporting ‘excellent’ or ‘very good.’ satisfaction with Palliative Care at St. John
    Satisfaction Results
    • We received our highest scores in the areas of ‘treatment with dignity,’ ‘inclusion of patients in decisions about care’ and ‘addressing spiritual needs.’
    • The highest number of negative comments focused on the discharge process from the hospital.
    Satisfaction Results
  • Financial Outcomes
  • Length-of Stay-Savings 2008 130 1329 Cases 2.6 days Savings/Case 8.5 Palliative Care 11.1 Usual Care LOS Service
  • Length-of-Stay Savings 188 2005 931 1730 918 Days Saved 2006 2007 2008 Year
  • Charge Avoidance - 2008 130 1329 Cases $14,449 Savings/Case $30,153 Palliative Care $44,602 Usual Care Charges/Case Service
  • Mean Charges Per Day 11 Days Prior to Death
    • 10 9 8 7 6 5 4 3 2 1
    • Days Before Death
  • Charge Avoidance $619,750 2005 $3,911,365 $3,062,573 $5,114,847 Charges Saved 2006 2007 2008 Year
  • Putting it Together, LOS and Cost Savings 3,767 Total Days Saved 2004 - 2008 $12,618,554 Total Charges Saved 2004 - 2008
  • Looking Ahead into the Future… Assume 15% Annual Growth Rate Charges Saved Days Saved Year $6,728,228 $5,852,808 $5,089,942 1775 2011 1544 2010 1343 2009
  • Should the Palliative Care Team See Every Patient in the Hospital?
  • Proactive palliative care in the medical ICU: effects on length of stay for selected high-risk patients Norton SA, Quill TE, et al. Critical Care Medicine 2007; 35:1530-1535
    • 17-bed medical ICU at a tertiary care hospital in Rochester, New York.
    • Primary Outcome: LOS
    • ICU admission following a current hospital stay 10 days or longer
      • Age >80 years with 2 or more life-threatening comorbidities
      • Active metastatic cancer
      • Status post cardiac arrest;
      • Intracerebral hemorrhage requiring mechanical ventilation
    Study Design Norton SA, Quill TE, et al. Crit Care Med . 2007; 35:1530-1535
  • Optional PC Consult Required PC Consult Mortality in the ICU Norton SA, Quill TE, et al. Crit Care Med . 2007; 35:1530-1535 P > 0.10
  • Total Days = 26.7 Non ICU Days Total Days = 33.9 ICU Days Required PC Consult Optional PC Consult Length of Stay Norton SA, Quill TE, et al. Crit Care Med . 2007; 35:1530-1535
  • Conclusions
    • Mandatory ICU Palliative Care Consultation reduced ICU stay over 7 days, without substantially changing mortality.
    • Non-ICU Hospital LOS did not decrease with the intervention
    Norton SA, Quill TE, et al. Crit Care Med . 2007; 35:1530-1535
  • Bottom Line
    • “ Blanket” Palliative Care Consultation can substantially reduce ICU days
    • Implied in the study is significant cost savings, but not explicitly reported.
    • More analysis could reveal clinical outcomes, satisfaction level, and referral patterns
    • The Oklahoma Advance Directive
    • a document only a lawyer could love…
  • Advance Directives
    • Statement of one’s wishes regarding End-of-Life Care
    • Only goes into effect when patients permanently lose decision-making capacity
    • Allows one to opt out of life-sustaining care and/or Artificial Nutrition and Hydration
    • Cumbersome document poorly understood by physicians and patients
    • Only executed by 15 - 20% of eligible patients
    Gillick, et al., Ann Int Med . 1995;123:621-624 OKLAHOMA ADVANCE DIRECTIVE FOR HEALTH CARE If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions below. I. Living Will If my attending physician and another physician determine that I am no longer able to make decisions regarding my medical treatment, I direct my attending physician and other health care providers, pursuant to the Oklahoma Advance Directive Act, to follow my instructions as set forth below: 1. If I have a terminal condition, that is, an incurable and irreversible condition that even with the administration of life-sustaining treatment will, in the opinion of the attending physician and another physician, result in death within six (6) Advance Directives
    • Surveys show that patients prefer their physicians to address Advance Directives in a controlled setting (e.g. office)
    • In reality, most Advance Directives are completed at a point of crisis, such as in a hospital during a critical illness
    Advance Directives Rodriguez, KL, et al., Soc Sci Med . 2006;62:125-133 Lo B, et al., Am J Geriatr Cardiol . 2004;13:316-320
  • Behold: The Mismatch
    • When surveyed, a majority of patients expect their Primary Care Physician to address Advance Care Planning.
    • Physicians generally do not solicit their patients about completing Advance Directives
    Tierney, et al. J Gen Intern Med 2001:16;32-40 Lurie, N. et al. J Am Geri Soc 1992:40;1205-8
  • Office Screening/Prevention
    • Diabetes Screening
    • Lipid Screening
    • PAP Smears
    • Mammography
    • Colonoscopy
    • PSA/DRE
    • Smoking Cessation Counseling
    • Advance Directive Completion
    • Alcohol/Drug Abuse Screening
  • Why is this conversation missing in Primary Care?
    • Thinking about dying is uncomfortable
    • Patients value invincibility
    • Physicians value cure
    • Physicians lack training
    • Legally complicated process (Missteps = Lawsuit)
    • Ethical hornet’s nest
    • Religious Implications
    • Time Issues
    • Portability Issues
    Tulsky J, et al. Ann Intern Med 1998:129;441-449
  • Can Residents be Trained to Address Advance Directives?
  • Study Characteristics
    • 10 Internal Medicine Residents
    • 100 Clinic Patients
    • All patients had to have at least one chronic illness to meet entry criteria
    • Baseline survey of 100 random charts revealed zero AD’s
  • Study Design
    • IRB approved, prospective survey trial
    • Residents were surveyed about their baseline knowledge, skills, attitudes and comfort using Advance Directives with patients.
    • Residents received 2-hour training period, reviewing all aspects of Advance Directives
  • Study Design
    • Once trained, each resident encouraged 10 of their ‘at-risk’ continuity patients to complete an Advance Directive
    • At the conclusion of the study, residents were re-surveyed about their knowledge, skills, attitudes and comfort using Advance Directives with patients.
  • p < 0.001 p < 0.001 p = 0.004 p < 0.001 Results: Residents
  • Conclusions
    • Residents significantly improved their knowledge, skills, attitudes, and comfort with Advance Directives in the Outpatient setting
    • Patients demonstrated a strong interest in completing Advance Directives
  • Implications from the Study The authors hoped that residents would apply their research experience to engage future patients in completing Advance Directives in the Outpatient setting. Did they?
  • Epi-Phenomenon Following the “conclusion” study period, Residents were secretly observed over a period of an additional 6 months Not one advance directive was completed in that period.
  • Bottom Line:
    • Despite intensive training, many barriers are stacked against physicians engaging their patients in meaningful conversations about Advance Directives
    • The doctor’s office is probably not the right place for patients to complete Advance Directives
  • Helping Zelda: What can we do?
  • What Zelda Needs:
    • Pain Management
    • Restoration of Function
    • Assistance with making difficult decisions
    • Workup and Treatment for Depression
    • Transition to appropriate venue of care
    • Advance Directive
  • What you can do:
    • Be a patient advocate
    • Recognize and treat patient suffering
      • Physical Suffering
      • Emotional Suffering
      • Social Suffering
      • Spiritual Suffering
  • What you can do:
    • Talk to your colleagues – do they recognize suffering?
    • Learn what resources your community offers in geriatrics and palliative care services
  • What you can do:
    • If Palliative Care is not in your community, encourage leadership to explore growth opportunities
    • www.capc.org
  • What you can do:
    • Complete EPEC/ELNEC training
    • Become certified in Palliative Medicine
    • Educate local providers, hospitals, and nursing homes to about Palliative Care
  • What you can do:
    • Familiarize yourself with the Oklahoma laws regarding Advance Directives
    • Encourage patients to execute Advance Directives, if they have not already done so.
    • Thank You